Abstract:The problem of nipple-areola complex (NAC) preservation during mastectomy is a very intriguing and stimulating issue. In fact, in order to perform an oncologically safe operation, no mammary tissue (enclosed in the main galactophoric ducts) should remain; on the other hand, without the blood supply coming from the breast gland, NAC viability is greatly impaired because the surrounding vascular dermal network is not developed enough to support its metabolic requirements. We suggest therefore a two-step surgical procedure. The first step, on an outpatient basis with local tumescent anesthesia, is a mini-invasive cutting and coagulating procedure. It addresses the autonomization of the vascular supply to the NAC by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. The second step, under general anesthesia and again with tumescent technique, removes the breast within its capsule, with careful checks of any remnant and adequate approach to the axilla. A subpectoralis prosthesis completes the procedure. In our view, this technique is electively suitable for prophylactic mastectomy, but also for stage I breast cancer, 2.5 cm from the NAC and 1.5 cm from the skin and pectoralis fascia, and it is very safe, simple, and effective. Key Words: delayed nipple-sparing modified subcutaneous mastectomy, mastectomy, nipple-areola complex preservation T he inheritable breast cancer recently detectable by evidence of the BRCA-1 / BRCA-2 gene mutation, lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ are currently faced on a preventive basis with selective screening and follow-up, chemoprevention, and /or prophylactic mastectomy (1-4). The surgical options of simple mastectomy and subcutaneous mastectomythe former excising the nipple-areola complex (NAC) together with the gland, the latter leaving intact the NACprovides 95 -99% and 90 -95% breast tissue removal, respectively, and thus being inadequate as to oncologic radicality (5). Therefore when risk of breast cancer is high, total mastectomy is the golden standard.A 13% increase (from 81% to 94%) of total mastectomies in cohorts of women with a family history of breast malignancy has been observed since 1995, followed by an high rate of reconstruction. Metcalfe et al. (6) report breast restoration in 60% of these patients, compared with 6 -13% of nonprophylactic mastectomies.Our study addresses the hypothesis of a new radical approach to subcutaneous mastectomy while retaining the integrity of the NAC, without leaving any gland stalk or parenchyma underneath, and thus obtaining complete clearance of the breast tissue. Primary reconstruction with subpectoralis prosthesis or two-stage replacement with an expander are the surgical options to complete the procedure in order to achieve satisfactory cosmetic results. This procedure addresses both cancer prophylaxis and stage I cancer treatment.
The aim of this paper was to evaluate the impact of breast-gland remodelling, for cosmetic or functional purposes, on cancer incidence during long-term post-surgical follow-up. We reviewed the literature investigating the ratio between the amount of breast tissue resected and cancer incidence during follow-up. Our analysis of the published data suggested that hypertrophic breast remodelling decreases the risk of breast and other types of cancer in post-operative patients. The actual risk reduction for patients over 40 years of age is related to the weight of the surgical specimens during the previous operation. Our conclusions support the use of breast-reduction surgery as a preventive measure in patients complaining of symptomatic breast enlargement, especially those with a family history of breast cancer.
Aims. The main aims of this paper are: (1) to evaluate the impact of partial breast gland removal, for cosmetic or functional reasons on cancer incidence in the long-term post-surgical follow-up; (2) to define the incidental cancer finding during breast reduction; (3) to examine the oncological perspective of contralateral breast reduction in women with post-mastectomy breast reconstruction, (4) to consider the impact of breast reduction techniques as first choice procedure in the treatment of cancers in megalomastia. Methods. We reviewed the clinical articles published in the last 20 years addressed to the relationship between the amount of tissue removed and cancerogenesis of the remnant gland. The review has been also extended to published papers outlining the future trends of breast reduction procedures from an oncological perspective, potentially as specific choice of selected cancer treatment in megalomastia. Results. Assessment of the literature data reveals that breast reduction does decrease the risk of breast and other types of cancers. The actual risk lowering for patients older than 40 is related to the amount of tissue removed. Conclusion. This study illustrates that breast reduction surgery should be encouraged, besides the known aims, as a preventive operation in those patients presenting degrees of breast hypertrophy and a family history of breast cancer.
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